Remote ultrasound diagnostics disrupting traditional military frontline healthcare delivery.

Accurate and reliable diagnostic capability is essential in deployed healthcare to aid decision-making and mitigate risk. This is important for both the patient and the deployed healthcare system, especially when considering the prioritisation of scarce aeromedical evacuation assets and frontline resources. Novel ultrasound tele-guidance technology presents a valuable diagnostic solution for remotely deployed military clinicians. This report discusses the first use of a consultant radiologist guiding a clinician, untrained in ultrasound, to perform an ultrasound scan via a live tele-guidance feed in the deployed environment using the Butterfly iQ+ tele-guidance system. Distance scanning provided a diagnostic quality report when compared with locally performed imaging to improve patient care and maintain operational output. This example demonstrates feasibility of remote point-of-care imaging systems in provision of location-agnostic high-quality diagnostic capability. Future opportunities to develop care pathways using bedside tele-diagnostics will democratise access, drive efficiency and improve patient care experience and outcomes.

Abdominal Near Infrared Spectroscopy can be reliably used to measure splanchnic oxygenation changes in preterm infants.

OBJECTIVE: Near-infrared spectroscopy (NIRS) allows assessment of regional tissue oxygen delivery and extraction. There are doubts regarding reliability of gut NIRS measurements. This study assesses reliability of NIRS for monitoring gut oxygenation. STUDY DESIGN: Splanchnic tissue haemoglobin index (sTHI), tissue oxygenation index (sTOI) and fractional tissue oxygen extraction (sFTOE) changes during blood transfusion were measured using NIRS and compared to stable control infants. Infants were grouped into 3 chronological age groups: 1-7, 8-28 and ≥29 days of life. RESULTS: sTHI, sTOI significantly increased, and sFTOE reduced following blood transfusion in all age group infants (n = 59), with no changes seen in control infants (n = 12). Baseline characteristics including gestational age and feed volumes did not differ between groups. CONCLUSION: Gut perfusion measured by NIRS improved in infants who received blood transfusion, a change not seen in the control group, thus suggesting NIRS is a reliable method to measure splanchnic tissue oxygenation.

Combat Application Tourniquet fares well in a chemical, biological, radiological or nuclear dress state.

INTRODUCTION: There is a need for a military tourniquet to control catastrophic haemorrhage in a chemical, biological, radiological or nuclear (CBRN) threat environment. No published data exist as to the efficacy of tourniquets while wearing British military CBRN individual protective equipment (IPE). METHODS: 12 volunteers from the counter CBRN instructors' course allowed testing on 24 legs. A Combat Application Tourniquet (C-A-T) was applied to all volunteers at the level of the midthigh. 12 legs were tested while wearing CBRN IPE (both operator and simulated casualty), and the control group of 12 legs was tested while wearing conventional combat dress state (both operator and simulated casualty). The order of leg laterality and dress state were sequenced according to a prerandomised system. Efficacy was measured via use of an ultrasound probe at the popliteal artery. Tourniquets were considered effective if arterial flow was completely occluded on ultrasound imaging. Data were collected on time to successful application, failure of tourniquets and pain scores as rated by the visual analogue scale (1-10). RESULTS: There were no failures of tourniquet application in the CBRN group, and two failures (17%) in the control group. Failures were pain threshold exceeded (n=1) and tourniquet internal strap failure (n=1). The mean application time for the CBRN group was 28.5 s (SD 11.7) and 23.7 s (SD 9.8) for the conventional combat group. There was no statistically significant difference (p=0.27). The median CBRN pain score was 2.0 (IQR 2.0-3.5). The median control pain score was 4.0 (IQR 3-6). This was a statistically significant difference (p=0.002). CONCLUSION: C-A-Ts applied to simulated casualties in CBRN IPE at the midthigh are at least as efficacious as those applied to the midthigh in a conventional combat dress state. The pain experienced was less in CBRN IPE than when in a conventional combat dress state.

Assessing the utility of head computed tomography in the role 2 hospital setting on operation TRENTON.

Operation TRENTON was the British government's humanitarian contribution to the United Nations Mission in South Sudan. This included the Bentiu-based role 2 medical facility, deployed to provide medical support to approximately 2000 UN peacekeepers and UN staff in the region of the country's largest Protection of Civilian camps. A portable CT brain scanner was installed due to concern over the risk of head injuries and the extended clinical timelines. We provide a short reflection on the utility of this imaging capability in the deployed role 2 environment.

Military assistance to the civil authority: medical liaison with the Manchester clinicians after the Arena bombing.

UK Defence Medical Services' personnel have experienced an intense exposure to patients injured during war over the last decade and a half. As some bitter lessons of war surgery were relearned and innovative practices introduced, outcomes for patients impr oved consistently as experience accumulated. The repository of many of the enduring lessons learnt at the Role 4 echelon of care remain at the Queen Elizabeth Hospital Birmingham (QEHB), with the National Health Service and Defence Medical Services personnel who treated the returning casualties. On 22 May 2017, a terrorist detonated an improvised explosive device at the Manchester Arena, killing 22 and wounding 159 people. In the aftermath of the event, QEHB was requested to provide support to the Manchester clinicians and teleconferencing and then two clinical visits were arranged. This short report describes the nature of the visits, outlines the principles of Military Aid to the Civil Authority and looks to the future role of the Defence Medical Services in planning and response to UK terrorism events.

The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet.

BACKGROUND: Exsanguination from limb injury is an important battlefield consideration that is mitigated with the use of emergency tourniquets. The Combat Application Tourniquet (C-A-T®) is the current British military standard tourniquet. METHODS: We tested the self-application of a newer tourniquet system, the Tactical Mechanical Tourniquet (TMT), against self-application of the C-A-T. A total of 24 healthy British military volunteers self-applied the C-A-T and the TMT to their mid thigh in a randomized, sequential manner. Popliteal artery flow was monitored with a portable ultrasound machine, and time until arterial occlusion was measured. Pain scores were also recorded. Results The volunteers allowed testing on their lower limbs (n = 48 legs). The C-A-T was applied successfully to 22 volunteers (92%), and the TMT was successfully applied to 17 (71%). Median time to reach complete arterial occlusion was 37.5 (interquartile range [IQR], 27-52) seconds with the C-A-T, and 35 (IQR, 29-42) seconds with the TMT. The 2.5-second difference in median times was not significant (ρ = .589). The 1-in-10 difference in median pain score was also not significant (ρ = .656). The success or failure of self-application between the two tourniquet models as assessed by contingency table was not significant (p= .137). CONCLUSION: The TMT is effective when self-applied at the mid thigh. It does not offer an efficacy advantage over the C-A-T.

Bomb blast imaging: bringing order to chaos.

Blast injuries are complex, severe, and outside of our everyday clinical practice, but every radiologist needs to understand them. By their nature, bomb blasts are unpredictable and affect multiple victims, yet require an immediate, coordinated, and whole-hearted response from all members of the clinical team, including all radiology staff. This article will help you gain the requisite expertise in blast imaging including recognising primary, secondary, and tertiary blast injuries. It will also help you understand the fundamental role that imaging plays during mass casualty attacks and how to avoid radiology becoming a bottleneck to the forward flow of severely injured patients as they are triaged and treated.

Large wind ripples on Mars: A record of atmospheric evolution.

Wind blowing over sand on Earth produces decimeter-wavelength ripples and hundred-meter- to kilometer-wavelength dunes: bedforms of two distinct size modes. Observations from the Mars Science Laboratory Curiosity rover and the Mars Reconnaissance Orbiter reveal that Mars hosts a third stable wind-driven bedform, with meter-scale wavelengths. These bedforms are spatially uniform in size and typically have asymmetric profiles with angle-of-repose lee slopes and sinuous crest lines, making them unlike terrestrial wind ripples. Rather, these structures resemble fluid-drag ripples, which on Earth include water-worked current ripples, but on Mars instead form by wind because of the higher kinematic viscosity of the low-density atmosphere. A reevaluation of the wind-deposited strata in the Burns formation (about 3.7 billion years old or younger) identifies potential wind-drag ripple stratification formed under a thin atmosphere.

Analysis of anti-protective antigen IgG subclass distribution in recipients of anthrax vaccine adsorbed (AVA) and patients with cutaneous and inhalation anthrax.

The anti-PA IgG1, IgG2, IgG3, and IgG4 subclass responses to clinical anthrax and to different numbers of anthrax vaccine adsorbed (AVA, BioThrax) injections were determined in a cross-sectional study of sera from 63 vaccinees and 13 clinical anthrax patients. The data show that both vaccination with three AVA injections and clinical anthrax elicit anti-PA IgG1, IgG2, and IgG3 subclass responses. An anti-PA IgG4 response was detected in AVA recipients after the fourth injection. The anthrax lethal toxin (LTx) neutralization efficacy of sera from recipients who received 4 to > or =10 AVA injections did not vary significantly in relation to changes in distribution of anti-PA IgG1 and IgG4 subclasses.

Contact dermatitis after henna skin tattooing.

A case of contact dermatitis resulting from temporary tattooing with henna is described. The skin was stained using a dye described as 'black' henna. This is produced by the addition of paraphenylenediamine (PPD) to traditional henna dye in order to make temporary skin tattoos appear darker. Sensitisation to PPD may also cause sensitivity to printers' inks, clothing dyes, hair dyes, local anaesthetics, sulphonamides, and para-aminosalicylic acid. The case of contact dermatitis described responded to application of topical steroid with no sequelae; however patients may be left with hypo- or hyper-pigmentation of the skin or even permanent scarring.

Periodically varying externally imposed environmental effects on population dynamics.

Effects of externally imposed periodic changes in the environment on population dynamics are studied with the help of a simple model. The environmental changes are represented by the temporal and spatial dependence of the competition terms in a standard equation of evolution. Possible applications of the analysis are on the one hand to bacteria in Petri dishes and on the other to rodents in the context of the spread of the Hantavirus epidemic. The analysis shows that spatiotemporal structures emerge, with interesting features which depend on the interplay of separately controllable aspects of the externally imposed environmental changes.

Impact of prenatal care with reduced frequency of visits in a residency teaching program.

OBJECTIVE: To determine if decreasing the number of prenatal visits for routine obstetric patients affects pregnancy outcome. STUDY DESIGN: A historical control study was designed to include 734 deliveries from January 1 to December 31, 1991, in women who had prenatal care per American College of Obstetricians and Gynecologists Committee Opinion no. 79, January 1990, guidelines for uncomplicated obstetric care. A prospective study cohort of women with 711 deliveries from January 1 to December 31, 1994, underwent prenatal care with modified guidelines to include: first visit at 6-12 weeks to confirm dating and obtain initial laboratory data, second visit at 16-20 weeks to obtain maternal serum alpha-fetoprotein screening, third visit at 24-28 weeks for 28-week laboratory data, fourth visit at 32 weeks, fifth visit at 36 weeks, sixth visit at 38 weeks, seventh visit at 40 weeks and weekly thereafter. Pregnancy outcomes included estimated fetal weight, gestational age at delivery, preeclampsia, Apgar score at one and five minutes and delivery mode. Neonatal outcomes, including stillbirth rate, preterm delivery rate, intraventricular hemorrhage rate, bronchopulmonary dysplasia and neonatal mortality, were evaluated. RESULTS: There were no statistically significant differences in perinatal or neonatal outcomes with decreased prenatal visits from an average of 12 per pregnancy to 8. CONCLUSION: Prenatal visits can be decreased in a teaching hospital in women with uncomplicated pregnancies from the standard number, 12-14 visits, to an average of 7 or 8 per patient without adverse perinatal outcomes.

Disturbance of cerebral function in people exposed to drinking water contaminated with aluminium sulphate: retrospective study of the Camelford water incident.

OBJECTIVE: To establish whether people exposed to drinking water contaminated with 20 tonnes of aluminium sulphate in the Camelford area of Cornwall in the south west of England in July 1988 had suffered organic brain damage as opposed to psychological trauma only. DESIGN: Retrospective study of affected people. PARTICIPANTS: 55 affected people and 15 siblings nearest in age to one of the group but who had not been exposed to the contaminated water were studied. MAIN OUTCOME MEASURES: Various clinical and psychological tests to determine medical condition and anxiety levels in affected people. Assessment of premorbid IQ (pFSIQ) with the national adult reading test, a computerised battery of psychomotor testing, and measurement of the difference in latencies between the flash and pattern visual evoked potentials in all participants. RESULTS: The mean (SE) pFSIQ was above average at 114.4 (1.1). The most sensitive of the psychomotor tests for organic brain disease was the symbol digit coding (SDC) test (normal score 100, abnormal <85). PARTICIPANTS performed less well on this test (54.5 (6.0)) than expected from their pFSIQ (P<0.0001) and a little less poorly on the averaged less discriminating tests within the battery (86.1 (2.5), P<0.0001). In a comparison with the 15 sibling pairs (affected people's age 41.0 (3.3) years v sibling age of 42.7 (3.1) years (P=0.36) the exposed people had similar pFSIQ (114.7 (2.1)) to their siblings (116.3 (2.1), (P=0.59) but performed badly on the symbol digit coding test (51.8 (16.6)) v (87.5 (4.9) for siblings, P=0.03). The flash-pattern differences in exposed people were greater than in 42 unrelated control subjects of similar age (27.33 (1.64) ms v 18. 57 (1.47) ms, P=0.0002). The 15 unexposed siblings had significantly better flash-pattern differences than their affected siblings (13.4 (2.4) ms v 29.6 (2.9) ms, P=0.0002). No effect of anxiety could be shown on these measurements from the analysis of the anxiety scores of exposed people. CONCLUSION: People who were exposed to the contaminated water at Camelford suffered considerable damage to cerebral function, which was not related to anxiety. Follow up studies would be required to determine the longer term prognosis for affected individuals.

Anterior femoral curvature revisited: race assessment from the femur.

The increasing need for accurate race assessment from postcranial skeletal remains has emphasized the lack of simple, replicable methods by which to accomplish the task. Several techniques have been proposed, but without adequate results. Anterior femoral curvature was first suggested and researched by T. Dale Stewart in 1962 (6). The technique used in that study was subjective at best. He provided no substantial discrimination between whites or blacks. Two later studies only reused Stewart's technique and/or data. This study was assumed to address these issues and provide an improved technique. Skeletal collections at the Smithsonian, as well as the forensic collections at the University of Florida and the University of Tennessee, provided the specimens for this study. The historical collection of the First African Baptist Church of Philadelphia, PA, and the modern forensic collection at Louisiana State University provided the test samples. Only black and white individuals were used, and those were selected based on previous soft tissue or positive identification. Thirteen measurements were taken, including six newly developed measures. Age, race, and sex were also documented. Discriminant analysis was used to develop functions for race assessment. After analyzing the data through SPSSx using Discriminant, the variables selected provided an accuracy of 88.15% using the right femur and 86.10% with the left femur. Age was divided into two groups: under 30 and over 30. Most skeletons can be easily aged into these categories.